Cecilia Ekéus

Preterm Birth, Social Disadvantage, and Cognitive Competence in Swedish 18- to 19-Year-Old Men

OBJECTIVE: The aim was to study the impact of a range of gestational ages (GAs) on cognitive competence in late adolescence and how this effect is modified by contextual social adversity in childhood. METHODS: This was a register study based on a national cohort of 119664 men born in Sweden from 1973 to 1976. Data on GA and other perinatal factors were obtained from the Medical Birth Register, and information on cognitive test scores was extracted from military conscription at the ages of 18 to 19 years. Test scores were analyzed as z scores on a 9-point stanine scale, whereby each unit is equivalent to 0.5 SD. Socioeconomic indicators of the childhood household were obtained from the Population and Housing Census of 1990. The data were analyzed by multivariate linear regression. RESULTS: The mean cognitive test scores decreased in a stepwise manner with GA. In unadjusted analysis, the test scores were 0.63 stanine unit lower in men who were born after 24 to 32 gestational weeks than in those who were born at term. The difference in global scores between the lowest and highest category of socioeconomic status was 1.57. Adjusting the analysis for the childhood socioeconomic indicators decreased the effect of GA on cognitive test scores by 26% to 33%. There was also a multiplicative interaction effect of social adversity and moderately preterm birth on cognitive test scores. CONCLUSIONS: This study confirms previous claims of an incremental association of cognitive competence with GA. Socioeconomic indicators in childhood modified this effect at all levels of preterm birth.

Increasing incidence of anal sphincter tears among primiparas in Sweden: A population-based register study

Background. The aim of this study was to examine the incidence and risk factors for anal sphincter tears (ASTs) at delivery. Methods. A national population‐based study was conducted with data from the Medical Birth Register including all primiparas with singleton pregnancy, who gave birth vaginally in Sweden from 1994 to 2004 (n = 365,886). Women with a third and fourth degree AST were compared with those who gave birth during the same period without incurring such tears. Results. The incidence of third degree AST increased by >60%, from 3.4% in 1994 to 5.2% in 2004 in spontaneous births, and from 8.7 to 14.8% in instrumental deliveries during the study period. The proportion of fourth degree AST increased from 0.3 to 0.55% in spontaneous births and from 0.8 to 1.4% in instrumental‐assisted deliveries during the same period. Compared with non‐instrumental delivery, vacuum extraction (VE) deliveries were related to an increased risk of AST. An infant birth weight of >4,000 g was also associated with an increased risk for both third and fourth degree AST. In addition, women born in Africa and Asia had significantly higher risk for both third and fourth degree AST compared to women born in Sweden. Conclusion. The incidence of third and fourth degree AST increased in both spontaneous births and instrumental deliveries. Instrumental delivery and an infant birth weight >4,000 g are the main risk factors for AST. Women from Africa and Asia have pronounced risks.

Risk factors for anal sphincter tears: the importance of maternal position at birth

Objective  To assess the role of birth position in the occurrence of anal sphincter tears (AST).

Maternal obesity during pregnancy as a risk for early-life asthma

Maternal smoking in early pregnancy 5.9% 13.1% Maternal smoking in late pregnancy 3.4% 23.4% Maternal asthma 5.8% Maternal diabetes 0.4% Maternal hypertension 0.4% Swedish-born mother 72% Maternal parity 1 49.2% 2 34.9% >_3 15.9% Maternal BMI Underweight (<18.5 kg/m) 3.0% 19.82% Normal (18.5-24.9 kg/m) 69.5% Overweight (25.0-29.9 kg/m) 20.1% Obese (30.0-34.9 kg/m) 5.3% Very obese (>_35 kg/m) 1.8% Pregnancy complications (ICD-10 code) Preeclampsia (O11, O14, or O15) 2.7% Gestational hypertension (O13) 1.0% Gestational diabetes (O244) 0.5% Birth and child details Proportion female subjects 48.7% Median (IQR) gestational age at delivery (wk) 40 (39-41) 0.1%

Psychiatric morbidity is related to parental age: a national cohort study

BACKGROUND The median age at first childbirth has increased dramatically in many high-income countries during the past decades. The psychiatric consequences of this demographic change are insufficiently described on a population level. This study aimed to investigate whether parental age at childbearing is related to psychiatric morbidity among Swedish youths. METHOD This was a cohort study based on Swedish national registers. A national cohort of 292129 children born to primiparas women during 1973-1979 was followed prospectively from 1987 to 2002 in registers. Multivariate Cox analyses of proportional hazards were used to estimate the relative risk of hospital admission for schizophrenia, alcohol and illicit drug abuse, suicide attempts and deaths. RESULTS Youths born of teenage mothers had a high risk for suicide death [relative risk (RR) 1.9, 95% confidence interval (CI) 1.3-2.7] and hospital admissions because of suicide attempt (RR 2.0, 95% CI 1.7-2.3) and substance abuse (alcohol: RR 1.6, 95% CI 1.4-1.8; illicit drug: RR 2.2, 95% CI 1.9-2.5) after adjustments for major sociodemographic confounders, compared with children of mothers aged 25-29 years. Offspring of older parents (>34 years) had the highest risk for schizophrenia (RR 1.8, 95% CI 1.0-3.0). CONCLUSIONS Parental age is related to psychiatric morbidity.

Unintentional and violent injuries among pre-school children of teenage mothers in Sweden: a national cohort study

Study objective: This study investigates the risk and mediating mechanisms of unintentional and violent injuries in pre-school children of teenage mothers. Design: Cohort study based on Swedish national registers. Cox analyses of proportional hazard were used to estimate the relative risk of hospital admission and death attributable to injuries in analyses of data from national registers. Participants: The study population was a national cohort of 800 192 children born in Sweden during 1987–93 who were followed up prospectively from birth to their 7th birthday. Main results: Children of teenage mothers had higher relative risks (RRs) of hospital admissions for violent as well as unintentional injuries; age adjusted RRs of 2.7 (95% CI 1.2 to 6.1) and 1.6 (1.4 to 1.8), respectively, for children of mothers under 18 years of age and 2.5 (1.6 to 3.8) and 1.5 (1.4 to 1.6) of mothers aged 18–19 are compared with those with mothers aged at least 32 at the birth of the child. When the models were adjusted to socioeconomic variables and indicators of parental substance misuse and psychiatric illness the risk decreased slightly but remained well above that of children with older mothers. In addition, children of teenage mothers had an increased risk of death attributable to violent injuries (RR 6.7 (2.6 to 16.0), as well as to unintentional injuries (RR 3.5 (2.0 to 6.1). Conclusions: Maternal age is an important determinant of injuries in pre-school children in Sweden and the children of teenage mothers are at particular risk. Young parents should be given priority in injury prevention programmes.

Vacuum assisted birth and risk for cerebral complications in term newborn infants: a population-based cohort study

BackgroundFew studies have focused on cerebral complications among newborn infants delivered by vacuum extraction (VE). The aim of this study was to determine the risk for intracranial haemorrhage and/or cerebral dysfunction in newborn infants delivered by VE and to compare this risk with that after cesarean section in labour (CS) and spontaneous vaginal delivery, respectively.MethodsData was obtained from Swedish national registers. In a population-based cohort from 1999 to 2010 including all singleton newborn infants delivered at term after onset of labour by VE (n = 87,150), CS (75,216) or spontaneous vaginal delivery (n = 851,347), we compared the odds for neonatal intracranial haemorrhage, traumatic or non-traumatic, convulsions or encephalopathy. Logistic regressions were used to calculate adjusted (for major risk factors and indication) odds ratios (AOR), using spontaneous vaginal delivery as reference group.ResultsThe rates of traumatic and non-traumatic intracranial hemorrhages were 0.8/10,000 and 3.8/1,000. VE deliveries provided 58% and 31.5% of the traumatic and non-traumatic cases, giving a ten-fold risk [AOR 10.05 (4.67-21.65)] and double risk [AOR 2.23 (1.57-3.16)], respectively. High birth weight and short mother were associated with the highest risks. Infants delivered by CS had no increased risk for intracranial hemorrhages. The risks for convulsions or encephalopathy were similar among infants delivered by VE and CS, exceeding the OR after non-assisted spontaneous vaginal delivery by two-to-three times.ConclusionVacuum assisted delivery is associated with increased risk for neonatal intracranial hemorrhages. Although causality could not be established in this observational study, it is important to be aware of the increased risk of intracranial hemorrhages in VE deliveries, particularly in short women and large infants. The results warrant further studies in decision making and conduct of assisted vaginal delivery.

Stillbirth among foreign-born women in Sweden

BACKGROUND The aims of this study were: (i) to investigate stillbirth risk in offspring to foreign-born women by region of birth; (ii) if disparities in risks can be explained by socio-economic factors, pregnancy complications or maternal morbidity; and (iii) if the risk varies by time since immigration. METHODS This was a population-based register study with data from the Swedish Medical Birth Register and socio-economic variables from national income and population registers. We studied single births from 1992 to 2005, and included 219,832 births to foreign-born women and 1,094,146 births to Swedish-born women. Logistic regression analysis was used to calculate odds ratios (ORs), using 95% confidence intervals (CIs). RESULTS In all, 4104 antepartal and 255 intrapartal stillbirths occurred. Compared with births to Swedish women, the OR of stillbirth was 2.27 (95% CI 1.84-2.80) for births to women from Africa and 1.41 (95% CI 1.22-1.64) for births to women from Middle East, after adjustment for confounding factors. The risk of stillbirth was higher in immigrants who had been in Sweden for a short time period (<5 years) compared with those who had been in Sweden for a longer period, OR 1.21 (95% CI 1.05-1.40). CONCLUSIONS The risk of stillbirth in immigrant women varies by region of birth and time since immigration, being highest in women from Africa and the Middle East, and the recently settled. Further studies are needed to identify the mechanisms behind these patterns.

Perceptions and experiences of female genital mutilation after immigration to Sweden: an explorative study.

AIM The aim of this study is to explore how women from part of the world where female genital mutilation (FGM) is normative perceive and experience FGM after immigrating to Sweden. METHOD Interviews were conducted with eight women from Djibouti, Eritrea, Ethiopia and Somalia. The data were analyzed using qualitative content analysis. RESULTS The womens feelings were ambivalent: though they opposed FGM, on the one hand, because of its negative effects on health, they acknowledged the practices positive cultural aspects on the other hand. The themes that emerged from the interviews are the role of FGM in ensuring virginity and protecting a familys honor, its role in avoiding shame and enhancing purity, social pressure experienced after immigration, an understanding of FGM as a symbol of the country of origin, and support for changing the tradition. CONCLUSION These findings indicate that women originating from communities where FGM is normative live in a context in which the practice is viewed as an important aspect of life even after immigration. More research concerning this complex and deeply rooted cultural issue is recommended.

The influence of fetal head circumference on labor outcome: a population-based register study

Objective. To investigate the association between postnatal head circumference and the occurrence of the three main indications for instrumental delivery, namely prolonged labor, signs of fetal distress and maternal distress. We also studied the association between postnatal fetal head circumference and the use of vacuum extraction and emergency cesarean section. Design. Population‐based register study. Setting. Nationwide study in Sweden. Population. A total of 265 456 singleton neonates born to nulliparous women at term between 1999 and 2008 in Sweden. Methods. Register study with data from the Swedish Medical Birth Register. Main outcome measures. Prolonged labor, signs of fetal distress, maternal distress, use of vacuum extraction and emergency cesarean section. Results. The prevalence of each outcome increased gradually as the head circumference increased. Compared with women giving birth to a neonate with average size head circumference (35 cm), women giving birth to an infant with a very large head circumference (39–41 cm) had significantly higher odds of being diagnosed with prolonged labor [odds ratio (OR) 1.49, 95% confidence interval (CI) 1.33–1.67], signs of fetal distress (OR 1.73, 95% CI 1.49–2.03) and maternal distress (OR 2.40, 95% CI 1.96–2.95). The odds ratios for vacuum extraction and cesarean section were thereby elevated to 3.47 (95% CI 3.10–3.88) and 1.22 (95% CI 1.04–1.42), respectively. The attributable risk proportion percentages associated with vacuum extraction and cesarean section were 46 and 39%, respectively among the cases exposed to a head circumference of 37–41 cm. Conclusions. Large fetal head circumference is associated with complicated labor and is etiological to a considerable proportion of assisted vaginal births and emergency cesarean sections.